PE and In-Patient Coverage Update

Posted By hmalone June 7, 2016

What you need to know:

IHCP released a banner on May 17, 2016 clarifying hospital in-patient coverage for presumptively eligible members.

Prior to this banner, if you did not receive a PE approval for a patient on the same date as the in-patient admit date, none of that stay would be covered under the PE benefit. IHCP is now clarifying that some services rendered during this visit may be covered.

→ Covered

If a hospital admission date is before the PE start date, and the in-patient service is reimbursed on a level-of-care (LOC) per diem basis, dates of service (DOS) on or after the member’s PE start date will be covered.

Some examples of LOC services are:

Burn cases

Psychiatric cases

Rehabilitation cases

× Not Covered

If the hospital admission date is before the PE start date, and the in-patient service is reimbursed using the Diagnosis-Related Grouper (DRG) methodology, no portion of that member’s in-patient stay will be considered a PE-covered service.

Providers can resubmit claims meeting the policy guidelines with dates of service back to February 15, 2015.